Hoofbeats: Hyponatremia Consult Case

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1. Reasoning is not just a cognitive process, but also a contextually situated activity. We do not reason in a vacuum. Unfamiliar environment, ambiguous clinical questions, relative domain expertise, emotional interference, personal comfort level of the case are examples of many contextual factors that can add to one's cognitive load AND alter their reasoning approach.
2. Situation awareness is something that precedes, prepares, and  “primes” our mode of thinking and is largely affected by a person’s goals and expectations. Having clearly defined clinical goals is crucial to effective reasoning.
3. When someone needs to operate with insufficient domain knowledge, there is the natural tendency to slow down AND to deploy different reasoning strategies such as backward reasoning. The process can be deliberate or completely unintentional.
   1. A clinician employing “hypothesis-driven reasoning” (“working backwards”) starts with a clinical problem, generates a series of hypotheses about the patient’s illness, then tests each of these against the available clinical data. It is a time and effort consuming process.
   2. How rigorously one deploys such a strategy is often not dependent on the person’s actual expertise but rather their perceived familiarity of the problem. “Cognitive ease” refers to the phenomenon when we face a common diagnosis or symptom, the impression of familiarity can create a false sense of ease, which makes us more susceptible to diagnostic errors.
4. Adaptive expertise entails someone’s ability to use existing clinical knowledge structures to come up with a novel solution when they face a complex, unfamiliar problem. An adaptive expert tends to have a solid knowledge structure of their own domain, is not satisfied by complacency, and is cognitively ready to brace novel knowledge in an unknown territory.

References

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Endsley MR. Toward a Theory of Situation Awareness in Dynamic Systems. Human Factors. 1995;37(1):32-64. doi:10.1518/001872095779049543

Endsley MR. Situation Awareness Misconceptions and Misunderstandings. Journal of Cognitive Engineering and Decision Making. 2015;9(1):4-32. doi:10.1177/1555343415572631

Durning S, Artino AR Jr, Pangaro L, van der Vleuten CP, Schuwirth L. Context and clinical reasoning: understanding the perspective of the expert's voice. Med Educ. 2011;45(9):927-938. doi:10.1111/j.1365-2923.2011.04053.x

Durning SJ, Artino AR, Boulet JR, Dorrance K, van der Vleuten C, Schuwirth L. The impact of selected contextual factors on experts' clinical reasoning performance (does context impact clinical reasoning performance in experts?). Adv Health Sci Educ Theory Pract. 2012;17(1):65-79. doi:10.1007/s10459-011-9294-3

Arocha JF, Wang D, Patel VL. Identifying reasoning strategies in medical decision making: a methodological guide. J Biomed Inform. 2005;38(2):154-171. doi:10.1016/j.jbi.2005.02.001

Mamede S, Schmidt HG, Rikers RM, Penaforte JC, Coelho-Filho JM. Breaking down automaticity: case ambiguity and the shift to reflective approaches in clinical reasoning. Med Educ. 2007;41(12):1185-1192. doi:10.1111/j.1365-2923.2007.02921.x

Carbonell KB, van Merrienboer JJG. Chapter 12: Adaptive Expertise. In: Ward P, Schraagen JM, Gore J and Roth EM, ed. The Oxford Handbook of Expertise. Oxford University Press, 2018. DOI: 10.1093/oxfordhb/9780198795872.001.0001

Croskerry P. Adaptive expertise in medical decision making. Med Teach. 2018;40(8):803-808. doi:10.1080/0142159X.2018.1484898

McBee E, Ratcliffe T, Schuwirth L, et al. Context and clinical reasoning : Understanding the medical student perspective. Perspect Med Educ. 2018;7(4):256-263. doi:10.1007/s40037-018-0417-x

Sandhu G, Ramaiyah S, Chan G, Meisels I. Pathophysiology and management of preeclampsia-associated severe hyponatremia. Am J Kidney Dis. 2010;55(3):599-603. doi:10.1053/j.ajkd.2009.09.027

Pu Y, Wang X, Bu H, Zhang W, Lu R, Zhang S. Severe hyponatremia in preeclampsia: a case report and review of the literature. Arch Gynecol Obstet. 2021;303(4):925-931. doi:10.1007/s00404-020-05823-9

Rotem R, Bilitzky A, Abady Nezer T, Plakht I, Weintraub AY. Clinical and laboratory markers in the recovery from severe preeclampsia. Pregnancy Hypertens. 2017;8:46-50. doi:10.1016/j.preghy.2017.03.003

Mylopoulos, M, Kulasegaram, K, Woods, NN. Developing the experts we need: Fostering adaptive expertise through education. J Eval Clin Pract. 2018; 24: 674– 677. https://doi-org.ezproxy.med.nyu.edu/10.1111/jep.12905

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Release Date: January 28, 2022

Expiration Date: January 28, 2025

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